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Oregon Department of Environmental Quality <br /> 1. General System Information <br /> The Existing System Evaluation Report form contains 8 pages.Some of the questions on this <br /> form may not pertain to the system being evaluated,as there are many system designs. If you (the <br /> septic system evaluator)are unable to answer any of the questions on this form please indicate, in <br /> writing,why this information was not available at the time the evaluation was completed. <br /> * The existing septic system consists of(check all that apply): <br /> x J Septic Tank Cesspool <br /> --- Dosing Tank x Disposal Trenches/Leach Lines <br /> Multi-compartment Tank Capping Fill <br /> Seepage Bed Sand Filter <br /> 'Other(please describe) <br /> Note:Cesspools may be used only to serve existing sewage loads and if failing,only be replaced with <br /> a seepage a epit system on lots that are too small to accommodate a standard system or other alternative <br /> Y Y <br /> onsite system. <br /> * There is a permit for the septic system x Yes !No Unknown <br /> * Permit Number(s) 95-15098 <br /> * Year original septic system installed: 1996 (YYYY) No record of installation date <br /> * Dates of subsequent repairs or alterations: (YYYY) <br /> * All plumbing fixtures are connected to the septic system Yes x No Unknown <br /> If you answered "No,"or"unknown,"please describe below: <br /> ALL PLUMBING FIXTURES WERE NOT TESTED AT TIME OF EVALUATION. <br /> * Additional Comments: <br /> 2. Overall Septic System Status <br /> * Discharge of sewage to the ground surface Yes No x None observed <br /> * Discharge of sewage to surface waters Yes No x None observed <br /> * Sewage backup into plumbing fixtures Yes 1 No x Unknown <br /> * Additional Comments: <br /> 3. Septic tank <br /> In order to fully describe the condition of the tank,the septic tank may need to be pumped. Please indicate <br /> below if the septic system tank was pumped during the course of this evaluation. <br /> * Septic tank was pumped during the course of this evaluation x ''Yes No <br /> * If the septic tank was NOT pumped during the course of this evaluation,please explain(e.g. <br /> septic system owner declined to have the tank pumped etc): <br /> Page 2 of 8 <br />